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1.
Zentralbl Chir ; 148(3): 228-236, 2023 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-37267977

RESUMO

BACKGROUND: Over the last two decades, sacral neuromodulation (SNM) has established its role in the treatment of functional pelvic organ-/pelvic floor disorders. Even though the mode of action is not fully understood, SNM has become the preferred surgical treatment of fecal incontinence. METHODS AND RESULTS: A literature search was carried out on programming sacral neuromodulation and long-term outcomes in treating fecal incontinence and constipation.Sacral neuromodulation was found to be successful in the long term. Over the years, the spectrum of indications has expanded, and now includes patients presenting with anal sphincter lesions. The use of SNM for low anterior resection syndrome (LARS) is currently under clinical investigation. Findings of SNM for constipation are less convincing. In several randomised crossover studies, no success was demonstrated, even though it is possible that subgroups may benefit from the treatment. Currently the application cannot be recommended in general.The pulse generator programming sets the electrode configuration, amplitude, pulse frequency and pulse width. Usually pulse frequency and pulse width follow a default setting (14 Hz, 210 s), while electrode configuration and stimulation amplitude are adjusted individually to the patient need and perception of stimulation.Despite low infection rates and few electrode-/pulse generator dysfunctions, up to 65% of patients require surgical reintervention during long term follow-up - in 50% of cases because of battery depletion, which is an expected event. At least one reprogramming is necessary in about 75% of the patients during the course of the treatment, mostly because of changes in effectiveness, but rarely because of pain. Regular follow-up visits appear to be advisable. CONCLUSION: Sacral neuromodulation can be considered to be a safe and effective long-term therapy of fecal incontinence. To optimise the therapeutic effect, a structured follow-up regime is advisable.


Assuntos
Terapia por Estimulação Elétrica , Incontinência Fecal , Doenças Retais , Neoplasias Retais , Humanos , Incontinência Fecal/terapia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Terapia por Estimulação Elétrica/métodos , Plexo Lombossacral/fisiologia , Resultado do Tratamento , Neoplasias Retais/terapia , Constipação Intestinal/terapia , Sacro
2.
Zentralbl Chir ; 144(2): 190-201, 2019 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-30934094

RESUMO

BACKGROUND: Fecal incontinence (FI) is often associated with significant suffering for affected patients and reduction of their quality of life. Fecal incontinence has an underestimated prevalence and will gain in importance in the future due to demographic change in Germany. During the last several years, new technologies have been developed and new evidence has been gathered for existing methods. The aim of this work is to highlight current developments and new treatment options for fecal incontinence. METHODS AND RESULTS: A review of recent literature on the treatment of fecal incontinence was conducted. For conservative therapy, the combination of various treatment options has been proven to be particularly effective. For surgical therapy, long term efficacy of sacral nerve stimulation has been confirmed. Sacral nerve stimulation is now considered first line therapy. Sphincteroplasty remains a valid treatment option in patients with FI due to a sphincter gap. Long term efficacy is low. "Bulking agents" are an alternative - predominantly in passive FI, although the evidence is limited due to the use of different substances and techniques, lack of long-term results and suboptimal study designs. For the treatment of FI in the context of a masked defecation disorder, ventral mesh rectopexy has become established. CONCLUSION: The spectrum of therapeutic options for the treatment of FI is continuously evolving. There is consensus that conservative treatment should be the initial therapy. Currently only a limited number of established surgical options are available. Development and evaluation of new treatment options and further improved evidence of efficacy of the existing treatment modalities are desirable.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Terapia por Estimulação Elétrica/métodos , Incontinência Fecal/terapia , Feminino , Alemanha , Humanos , Masculino , Qualidade de Vida , Sacro , Resultado do Tratamento
3.
Langenbecks Arch Surg ; 389(3): 178-83, 2004 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15188084

RESUMO

BACKGROUND: Objective of the study was to investigate particular clinicopathological features of colorectal signet-ring cell carcinoma. METHODS: The data of 34 patients with primary colorectal signet-ring cell carcinoma were compared with those of 4,458 consecutive patients with primary non-signet-ring cell colorectal adenocarcinoma between 1978 and 1999. For outcome analysis patients, after curative resection of signet-ring cell cancer, were matched for age, gender, tumour site and stage with patients suffering from poorly differentiated non-signet-ring cell colorectal adenocarcinoma. RESULTS: Signet-ring cell carcinoma patients were significantly younger than patients with non-signet-ring cell colorectal adenocarcinoma (median age 60 years vs 64 years, P=0.033). The most common tumour sites were the rectum (47%) and the right hemicolon (29%). They presented with significantly more advanced tumour stages and a significantly higher frequency of distant metastases (44% vs 21%, P=0.002). The rate of curative resections was significantly lower (35% vs 79%, P<0.001). However, the prognosis after curative resection of signet-ring cell cancer was as poor as in poorly differentiated non-signet-ring cell colorectal adenocarcinoma of the same stage (5-year survival rate 46% vs 57%, p=0.935). CONCLUSIONS: Colorectal signet-ring cell carcinoma is characterized by diagnosis in more advanced tumour stages resulting in lower rates of curative resection. Prognosis is as poor as in non-signet-ring cell colorectal cancer of low differentiation in the same stage.


Assuntos
Carcinoma de Células em Anel de Sinete/patologia , Neoplasias do Colo/patologia , Neoplasias Retais/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células em Anel de Sinete/mortalidade , Carcinoma de Células em Anel de Sinete/cirurgia , Neoplasias do Colo/mortalidade , Neoplasias do Colo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Neoplasias Retais/mortalidade , Neoplasias Retais/cirurgia
4.
Anticancer Drugs ; 14(9): 745-9, 2003 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-14551509

RESUMO

Our objective was to evaluate the efficacy and safety of high-dose 5-fluorouracil (5-FU) as a 24-h infusion and folinic acid (FA) (AIO regimen) plus irinotecan (CPT-11) after pre-treatment with AIO plus oxaliplatin (L-OHP) in colorectal carcinoma (CRC). Twenty-six patients with non-resectable distant CRC metastases were analyzed for second- or third-line treatment with AIO plus CPT-11 after pre-treatment with AIO plus L-OHP. On an outpatient basis, the patients received a treatment regimen comprising weekly 80 mg/m2 CPT-11 in the form of a 1-h i.v. infusion and 500 mg/m2 FA as a 1- to 2-h i.v. infusion, followed by 2000 mg/m2 5-FU i.v. administered as a 24-h infusion once weekly. A single treatment cycle comprised six weekly infusions followed by 2 weeks of rest. A total of 26 patients received 344 chemotherapy applications with AIO plus CPT-11. The main symptom of toxicity was diarrhea (NCI-CTC toxicity grade 3+4) occurring in five patients (19%; 95% CI 7-39%). Nausea and vomiting presented in two patients (8%; 95% CI 1-25%). The response rate of 26 patients can be summarized as follows: partial remission: n=7 (27%; 95% CI 12-48%); stable disease: n=9 (35%; 95% CI 17-56%) and progressive disease: n=10 (38%; 95% CI 20-59%). The median progression-free survival (n=26) was 5.8 months (range 3-13), the median survival time counted from the treatment start with the AIO plus CPT-11 regimen was 10 months (range 2-24) and counted from the start of first-line treatment (n=26) was 23 months (range 10-66). We conclude that the AIO regimen plus CPT-11 is practicable in an outpatient setting and well tolerated by the patients. Tumor control was achieved in 62% of the patients. The median survival time was 10 months and the median survival time from the start of first-line treatment (n=26) was 23 months.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Camptotecina/análogos & derivados , Neoplasias Colorretais/tratamento farmacológico , Fluoruracila/administração & dosagem , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Camptotecina/administração & dosagem , Diarreia/induzido quimicamente , Esquema de Medicação , Feminino , Humanos , Infusões Intravenosas , Irinotecano , Leucovorina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Compostos Organoplatínicos/administração & dosagem , Oxaliplatina , Estudos Retrospectivos , Vômito/induzido quimicamente
5.
J Surg Res ; 113(2): 179-88, 2003 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-12957127

RESUMO

BACKGROUND: Tumor response to radiochemotherapy (RCT) varies considerably, even among patients treated in accordance with the same protocol. The aim of the present study was to test the predictive value of the cell-cycle inhibitor p27kip1 with regard to neoadjuvant RCT response in rectal cancer. MATERIALS AND METHODS: P27kip1 was evaluated by immunohistochemistry in pretreatment biopsy material obtained from 42 patients with rectal cancer treated uniformly in accordance with an identical prospective neoadjuvant RCT protocol (CAO/AIO/ARO-94). Four expression patterns (staining intensity [-,+,++,+++] and the percentage of positive cells, evaluated separately for nuclei and cytoplasm) of p27kip1 were investigated for correlation with tumor response, which was assessed in the resected surgical specimen using a histopathological five-point grading system. Additionally, p27(kip1) expression was investigated for correlation with several pathological features, overall survival, and disease-free survival. RESULTS: p27kip1 expression was as follows: nuclear intensity: -: 8, +: 19, ++: 11, +++: 4 cases, median percentage of positive cells: 18.75%; cytoplasmic intensity: -: 0, +: 25, ++: 12, +++: 3 cases, median percentage of positive cells: 70%. Histopathological tumor regression was acceptable in 30 patients (3 complete; 27 good) and inadequate in 12 patients (7 moderate; 5 minimal). No tumor failed to show some regression. No significant correlation was found between any of the p27kip1 expression patterns and RCT response, tumor differentiation (low grade versus high grade), cT- and ypT-category, UICC stage, overall survival, and disease-free survival. CONCLUSIONS: p27kip1 cannot aid the individualization of multimodal treatment strategies in rectal cancer, nor can it serve as a predictor of survival.


Assuntos
Adenocarcinoma/metabolismo , Adenocarcinoma/terapia , Biomarcadores Tumorais/biossíntese , Proteínas de Ciclo Celular/biossíntese , Quinases Ciclina-Dependentes/biossíntese , Neoplasias Retais/metabolismo , Neoplasias Retais/terapia , Proteínas Supressoras de Tumor/biossíntese , Adulto , Idoso , Antimetabólitos Antineoplásicos/uso terapêutico , Colectomia/métodos , Terapia Combinada , Inibidor de Quinase Dependente de Ciclina p27 , Feminino , Fluoruracila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Radioterapia Adjuvante/métodos , Indução de Remissão , Estudos Retrospectivos , Análise de Sobrevida
6.
J Photochem Photobiol B ; 70(1): 13-20, 2003 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-12745242

RESUMO

To evaluate the new, bio-optical method of light-induced autofluorescence spectroscopy for the endoscopic in-vivo diagnosis of (pre)-cancerous lesions of the colorectum, 311 endogenous fluorescence spectra were obtained from normal, adenomatous and cancerous colorectal tissue in 11 patients with cancer, six patients with familial adenomatous polyposis, and six patients with multiple adenomatous polyps. A light source delivered either white or violet-blue light for excitation of tissue autofluorescence via a flexible endoscope. Endogenous fluorescence spectra emitted by the tissue were picked up with a fiberoptic probe and analysed with a spectrograph. Biopsies were taken for definitive classification of the spectra. Rectal cancer (n=11) as well as adenomas with severe dysplasia (n=19) showed specific differences between the emitted fluorescence spectra as compared with normal mucosa and hyperplastic polyps. Having applied a mathematical algorithm to the spectra, a sensitivity of 96% and a specificity of 93% were obtained for the diagnosis of rectal cancer. The equivalent values for the diagnosis of dysplastic ademomas were 98 and 89%, respectively. Light-induced autofluorescence spectroscopy is a new and promising bio-optical procedure for the endoscopic in-vivo diagnosis of colorectal cancer and dysplasia.


Assuntos
Adenoma/diagnóstico , Polipose Adenomatosa do Colo/diagnóstico , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Gastroscopia/métodos , Neoplasias Retais/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Pólipos do Colo/diagnóstico , Desenho de Equipamento , Feminino , Humanos , Mucosa Intestinal/citologia , Mucosa Intestinal/patologia , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Espectrometria de Fluorescência , Xenônio
7.
Langenbecks Arch Surg ; 387(11-12): 406-10, 2003 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-12607120

RESUMO

BACKGROUND: Anastomotic leakage is the most threatening early complication in sphincter-preserving rectal cancer surgery. While the oncological consequences have been well examined, only few data exist about the functional outcome. PATIENTS AND METHODS: We investigated continence function in 150 patients after curative sphincter-preserving rectal cancer surgery. Functional results were compared in 22 patients with a clinically relevant anastomotic leakage, confirmed radiologically or endoscopically, and 128 patients with uneventful recovery. Evaluation of continence function was based on the Cleveland Clinic Continence Score and was examined in all patients with anastomotic leakage and in 111 patients without complications 107+/-46 weeks postoperatively. Additionally, 14 patients with anastomotic leakage and 58 patients with uneventful recovery underwent anorectal manometry 26+/-15 weeks postoperatively. RESULTS: The continence score in patients after anastomotic leakage did not differ significantly from that in patients without complications. Sphincter function was similar. Maximum tolerable volume and rectal compliance were slightly but not significantly worse after leakage. CONCLUSIONS: Continence function remained undisturbed after anastomotic leakage due to rectal resection


Assuntos
Anastomose Cirúrgica , Incontinência Fecal/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Neoplasias Retais/cirurgia , Deiscência da Ferida Operatória/fisiopatologia , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Neoplasias Retais/fisiopatologia , Reto/fisiopatologia , Reto/cirurgia , Estatísticas não Paramétricas , Inquéritos e Questionários , Falha de Tratamento
8.
Int J Colorectal Dis ; 17(6): 430-4, 2002 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-12355221

RESUMO

BACKGROUND AND AIMS: The somatomotor innervation pattern has been shown to differ in patients undergoing percutaneous nerve evaluation for sacral nerve stimulation. In some patients bilateral stimulation might improve clinical outcome; however, only single-channel pulse generators have until now been available. We report a patient with fecal incontinence after surgery for rectal carcinoma in whom a dual-channel, individually programmable, pulse generator permitted implantation of neurostimulation electrodes bilaterally. PATIENTS AND METHODS: Intractable fecal incontinence developed in a 48-year-old man who underwent low anterior rectum resection, owing mainly to reduced internal anal sphincter function. The morphology of the anal sphincter was without defect. Based on the findings of unilateral and bilateral temporary sacral nerve stimulation the patient underwent placement of foramen electrodes on S4 bilaterally. Both electrodes were connected to a dual-channel impulse generator for permanent low-frequency stimulation. RESULTS: The percentage of incontinent bowel movements decreased during unilateral test stimulation from 37% to 11%, during bilateral test stimulation to 4%, and with chronic bilateral stimulation to 0%. The Wexner continence score improved from 17 preoperatively to 2, and quality of life (ASCRS score) was notably enhanced. Anorectal manometry revealed improved striated anal sphincter function; the internal anal sphincter remained unaffected. CONCLUSION: Sacral nerve stimulation can effectively treat incontinence after rectal resection, and bilateral stimulation can improve the therapeutic effect.


Assuntos
Terapia por Estimulação Elétrica/métodos , Incontinência Fecal/terapia , Plexo Lombossacral/fisiologia , Neoplasias Retais/cirurgia , Eletrodos Implantados , Incontinência Fecal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Reto/inervação
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